Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Today I was reading a column by the inimitable Mr. HISTalk in which he argued that EMRs really can do a major disservice to patients. One way in which they do so, he suggests, is inherent in their design:

“EMRs try to turn freeform and sometimes tentative thoughts into dropdowns and template-driven generic verbiage that may destroy their original context (that’s what programmers do: impose order and create retrievable database information, so it’s not really their fault).”

I found this to be pretty interesting, because it highlighted a problem not discussed a lot in this space. To wit, it points out that dropdowns, templates and the like aren’t just frustrating — they’re actually forcing doctors to document care in pre-prescribed ways which may or may not suit the physician’s line of thought. After all, in a template-and-dropdown environment, there’s little room for thinking out loud, suggesting theories or making unorthodox observations.

Ideally, the notes physicians enter or dictate should represent the best of their judgment, but also their intuition. Not only is intuition necessary to determine the best course of care for patients, it’s a critical tool for divining when something is out of order, be it a test result, the patient’s current diagnosis or something in the history that doesn’t fit.

And here you have the essential conflict between EMR-driven medicine and “old fashioned” methods. As Mr. HISTalk points out, it’s the job of the EMR makers to normalize data such that it can be abstracted, shared and studied. But it’s the job of the doctor to solve the problem that shows up in front of them, whether it can be described easily using a template or not.

Now, I’m not suggesting, as many have, that EMRs can’t be evolved into tools which are flexible enough to both support physicians’ process. But I do think it’s important to focus in on issues like these, as they’re still very much in play.

This reminds me a little of a similar problem, though less devastating in terms of patient care, in terms of coding. Often the code “isn’t quite right” but we are forced to pick one. Like having a code for a chin laceration–well there’s a code for open wound, but not laceration. Or benign hypertension vs malignant hypertension, neither of which quite fit but my auditing people tell me how I MUST code with jaw dropping ignorance of the medical facts. Hopefully ICD 10 will help. The complexity of the EHR and the possibility of fitting square patients into round holes complicated by the very real likelihood that the MD will finally just pick something in frustration so he can move on to the next patient–shuddering to think about.

Dr. Nieder,
Good comparison. That is similar in many ways. I know I deal with counseling diagnosing a lot. They’d often do what they called a rule out diagnosis. Unfortunately, EMR doesn’t handle that very well. There’s no nuance to how firm you feel about the diagnosis either. Most EMR don’t capture those subtleties.

While it is true the template driven systems are definitely a challenge because they are the results of programmers trying to capture the complexity of a medical visit, template-driven EHR isn’t the only option. Aprima is a non-template, Chief Complaint driven system. It isn’t a serial approach to documentation, but rather it mimics the workflow of a provider and the way they are taught to think and document in medical school. By intuitively understanding the type of problem or problems presented, and how a provider typically handles it/them, clinically relevant information is presented to the provider instead of the provider having to go find it via pointing and clicking. Preferences and habits are saved and the more often a given problem is treated in the same manner the faster and more efficient the provider is able to document, including any exceptions which are just as important. Free text doesn’t have to be the evil of structured documentation when you shed the handcuffs of traditional templates.

I’ve worked with a few different EHRs that have some template-driven documentation tools but all of them allow free text additions, comments, or even completely free-text sections. There is absolutely nothing about them that prevents the physician from easily adding the nuances they need to add, nor anything that forces them into inaccurate documentation. Maybe there are some poorly-designed EHRs out there, but if so this problem would be a feature of the product itself and has nothing to do with the concept of an EHR.

I think the original concept is incorrect, and trying to make an issue where there isn’t one.